Hospital improves cure rate of bone and joint infections with oral antibiotics
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A hospital improved the cure rate of bone and joint infections from 50% to 80% with partial-oral antibiotic treatment and carefully coordinated post-discharge care, according to a study published in Open Forum Infectious Diseases.
“There has been a paradigm shift to treat bone and joint infection (BJI) with oral antibiotics, but the landmark trial OVIVA did not include people who inject drugs (PWID),” Wei-Teng Yang, MD, MPH, addiction medicine fellow at Oregon Health & Science University, told Healio.
“Traditionally, this marginalized group was treated with an ‘all-or-none’ approach — either they were asked to stay in the hospital for the entire 6 to 12 weeks of IV antibiotics because most physicians did not feel comfortable discharging them with a long-term IV catheter, fearing the catheter would be used to inject drugs, or they left the hospital on their own ‘patient-directed discharge’ without any antibiotics,” Yang continued.
According to Yang, the traditional dogma is that this type of infection should be treated with IV antibiotics, and oral antibiotic treatment was not an option until OVIVA.
In the new study, Yang and colleagues noted that a previous study showed that PWID with BJI who were treated with prolonged IV antibiotic therapy at Harborview Medical Center in Seattle achieved a 50% cure rate, “even with bundled interventions” that included ID consultation, addiction medicine consultation, case management, medications for opioid use disorder, and post-discharge care in a medical respite.
To provide evidence that giving PWID oral antibiotics with careful planning after discharge can achieve a reasonable outcome without compromising the patient’s autonomy, Yang and colleagues conducted a retrospective study of all PWID reporting drug use within 3 months and BJI requiring 6 or more weeks of antibiotics at the same hospital between Feb. 1, 2019, and Feb. 1, 2021.
Treatment outcomes and rates of failure — defined as death, symptoms or signs raising concern for worsening or recurrent infections — were assessed at 90 and 180 days after completion of antibiotics.
According to the study, 705 patients with BJI were identified — 86 of whom were PWID who were included in the final study cohort. Among these 86, 51% were homeless, 58% had spine infection, 79% had surgery and 47% had postoperatively retained hardware. Additionally, 12 (14%) of the patients received exclusively IV antibiotics and 74 (86%) received partial-oral antibiotics, whereas 12 (14%) patients had patient-directed discharge (PDD).
Overall, the researchers found that rates of failure at 90 days and 180 days were similar across all-IV and partial-oral groups. Among 74 patients in the partial-oral group, the failure rates were 20% and 21% at 90 and 180 days, respectively. Among the group receiving planned partial-oral antibiotics, failure rates were 18% at 90 days and 20% at 180 days. Among patients who opted for PDD, four experienced treatment failure, one died after surgery and two were lost to follow-up, while eight others were readmitted — seven of whom within 30 days.
According to the study, homelessness upon hospitalization, follow-up with infectious diseases specialists or surgery and discharge to medical respite were associated with lower ORs of failure, although the researchers noted that the low OR associated with homelessness appeared to be mediated by discharge to the medical respite.
“We should keep harm reduction and patient autonomy in mind to offer alternative antibiotic to the traditional IV entire-course antibiotic treatment,” Yang said. “This obviously still needs careful consideration and arrangements of a lot of resources but can be a patient-centered realistic approach to cure their infections.”
He added that the study also highlights the importance of concurrent substance use treatment in the hospital.
“Our thoughts were once we can stabilize patients' substance use disorders (primarily opioid use disorder), oral antibiotics should be a practical option,” Yang said. “In our study, more than 80% of patients received consultation from addiction medicine, and about the same percentage of patients received treatment for opioid use disorder. I do not think we would be able to achieve the same cure rate without the collaboration with the addiction medicine team.”
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